Provider Demographics
NPI:1922085083
Name:MICHELSEN, CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:MICHELSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1891 COLBY LN
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4381
Mailing Address - Country:US
Mailing Address - Phone:815-494-8893
Mailing Address - Fax:
Practice Address - Street 1:3524 E MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-1626
Practice Address - Country:US
Practice Address - Phone:608-756-7100
Practice Address - Fax:608-756-4700
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36071282207Q00000X
WI28265207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIMICHECRAOtherMERCYCARE INSURANCE
ILB55081Medicare UPIN
WIMICHECRAOtherMERCYCARE INSURANCE
WI541760821Medicare PIN